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On admission assessment, the nurse is obtaining subjective data about a client's sexual and reproductive status. The client states, 'I don't want to discuss this; it's private and personal.' Which response by the LVN/LPN is the most therapeutic?
- A. I'd hate being asked these sorts of questions too, but it's a necessary part of providing you with the best care.
- B. This is difficult for you to speak about, but I need this information from you in order to perform a complete assessment.
- C. I am a professional registered nurse, and, as such, I'll have you know that all your information is certainly kept confidential.
- D. I know that some of these questions are difficult for you, but, as a professional nurse, I am obligated to respect your confidentiality.
Correct Answer: D
Rationale: The correct response is D. Respecting the client's privacy while acknowledging the difficulty of the situation and explaining the professional obligation to maintain confidentiality is the most therapeutic approach. This response shows empathy, understanding, and a commitment to confidentiality, which can help build trust and encourage the client to open up. Choices A, B, and C do not effectively address the client's concerns or emphasize the importance of confidentiality in a sensitive manner, making them less therapeutic responses in this situation.
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The charge nurse is collaborating with the nursing staff about the plan of care for a client who is very depressed. What is the most important intervention to implement during the first 48 hours after the client's admission to the unit?
- A. Monitor appetite and observe intake during meals.
- B. Maintain safety in the client's environment.
- C. Provide ongoing, supportive contact.
- D. Encourage participation in activities.
Correct Answer: B
Rationale: The most critical intervention to implement during the first 48 hours after admitting a depressed client is to maintain safety (B). Depression increases the risk of suicide; hence ensuring a safe environment is the priority. While monitoring appetite (A), providing supportive contact (C), and encouraging participation in activities (D) are important aspects of care for a depressed client, ensuring safety takes precedence in the initial phase of admission.
A client is admitted with a diagnosis of depression. The nurse knows that which characteristic is most indicative of depression?
- A. Grandiose ideation.
- B. Self-destructive thoughts.
- C. Suspiciousness of others.
- D. A negative view of self and the future.
Correct Answer: D
Rationale: A negative view of self and the future (D) is a prominent characteristic of depression. It reflects the core symptoms of low self-esteem and hopelessness that are commonly associated with this condition. Grandiose ideation (A) and suspiciousness of others (C) are more indicative of other mental health disorders like paranoia. While self-destructive thoughts (B) can be present in depression, they are not as specific and common as the negative self-view and hopelessness, making option (D) the most indicative characteristic of depression.
A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or phone calls since admission. He reports he has no family that cares about him and was living on the streets prior to this admission. According to Erikson's theory of psychosocial development, which stage is the client in at this time?
- A. Isolation.
- B. Stagnation.
- C. Despair.
- D. Role confusion.
Correct Answer: B
Rationale: The client is in Erikson's 'Generativity vs. Stagnation' stage (age 24 to 45). This stage involves maintaining intimate relationships and moving toward developing a family, which the client seems to be struggling with due to lack of visitors and family support. Choices (A), (C), and (D) are incorrect. Isolation typically occurs in young adulthood (age 18 to 25), Despair in maturity (age 45 to death), and Role confusion in adolescence (age 12 to 20). These stages reflect challenges individuals face if they do not successfully navigate their psychosocial developmental tasks.
The parents of a nuclear family attending a support group for parents of adolescents are being assessed by the nurse. According to Erikson, these parents who are adapting to middle adulthood should exhibit which characteristic?
- A. Loss of independence.
- B. Increased self-understanding.
- C. Isolation from society.
- D. Development of intimate relationships.
Correct Answer: B
Rationale: The correct answer is B: Increased self-understanding. According to Erikson's psychosocial development theory, middle adulthood is characterized by generativity, self-reflection, understanding, and acceptance. Middle-aged adults focus on guiding the next generation and finding meaning in their lives. Choices A and C are incorrect because loss of independence and isolation from society are maladaptive behaviors in middle adulthood. While developing and maintaining intimate relationships is important throughout life, the initial development of intimate relationships typically occurs during young adulthood, not middle adulthood.
A client with Alzheimer's disease is becoming increasingly agitated and combative in the late afternoon. What is the most appropriate intervention?
- A. Offer a sedative medication to calm the client.
- B. Encourage the client to rest in a quiet, low-stimulation environment.
- C. Use reality orientation to reduce confusion.
- D. Engage the client in physical activity to reduce agitation.
Correct Answer: B
Rationale: Encouraging the client to rest in a quiet, low-stimulation environment is the most appropriate intervention for a client with Alzheimer's disease who is becoming agitated and combative in the late afternoon. This approach helps reduce agitation and prevent overstimulation, providing a calming and soothing environment for the client. Offering a sedative medication (Choice A) should be avoided as it may have side effects and should only be considered as a last resort. Reality orientation (Choice C) may increase confusion and distress in clients with advanced Alzheimer's disease. Engaging the client in physical activity (Choice D) could potentially escalate the agitation rather than reduce it in this scenario.